Engaging Community in Prioritizing Outcomes to Improve Family Health in Evidence-Based Nurse Home Visiting: Using a Modified e-Delphi Method

BACKGROUND

Evidence-based home visiting programs are designed to improve maternal child health. Nurse-Family Partnership (NFP) is a model evidence-based home visiting program, shown to improve pregnancy outcomes, child development, and economic self-sufficiency for first-time mothers and their families experiencing social and economic adversities, enrolling them early in pregnancy. Recently, NFP has expanded its services to multiparous women (previous live births) and enrolling women past 28 weeks gestation (late registrants) in selected agencies in Florida since 2021.

OBJECTIVE

To study the process and impacts of expanding NFP to expanded populations (multiparous and/or late registrants), we convened a diverse Advisory Committee to guide the NFP expansion evaluation in Florida.

METHODS

This study employed a modified e-Delphi method with three rounds of data collection, to engage diverse partners to identify process and impact outcomes for the NFP expansion evaluation.

RESULTS

Child maltreatment was identified as the highest priority outcome. Process outcomes included program reach, client enrollment, and client engagement, while impact outcomes included maternal physical health, maternal mental health and substance use, birth outcomes, and breastfeeding practices. The Advisory Committee further identified potential data sources to measure these outcomes.

CONCLUSIONS FOR PRACTICE

Identifying and selecting key process and impact outcomes using a community-engaged process is necessary to ensure equal buy-in from all partners and to inform rigorous program evaluation. This study showed that using methods such as e-Delphi is feasible and effective for achieving thoughtful and rigorous decision-making, even in times of uncertainty like the COVID-19 pandemic.

Short-term patient-centered nutrition counseling impacts weight and nutrient intake in patients with systemic lupus erythematosus

BACKGROUND

Patients with systemic lupus erythematosus (SLE) are at a high risk for cardiovascular disease (CVD) due to increased prevalence of traditional and nontraditional CVD risks factors.

OBJECTIVE

To evaluate the effect of patient-centered nutrition counseling methods on changes in select nutrient, anthropometric, and clinical outcomes in SLE patients enrolled in a CVD prevention counseling program (CVD PCP).

METHODS

From March 2009 to June 2011 a subgroup of SLE patients enrolled in our CVD PCP were referred to a registered dietitian for individualized nutrition counseling. Outcomes of interest were assessed at baseline and six months. A primary analysis evaluated the six-month changes in nutrient intake, weight, body mass index (BMI), waist circumference, and lipid levels. A secondary analysis compared the same measurements between the nutrition counseling patients and the group that was referred but did not attend.

RESULTS

Of 71 referrals, 41 (58%) attended nutrition counseling (female: 89%, African American/Hispanic: 72%, mean age of 39.7 ± 12.82 years, and a mean disease duration of 11.49 ± 8.02 years). Over a six-month period, patients attending nutritional counseling: (a) reduced their intake of sodium (p = 0.006), total calories (p = 0.07), and percent calories from fat (p = 0.011) and saturated fat (p = 0.068); (b) had decreased weight (-1.64 kg, p = 0.025); and (c) were more likely to report increases in eating a diet rich in fruits and vegetables (p < 0.001), a high fiber diet (p = 0.011), ≥two servings of fish/week (p = 0.002), and a low cholesterol diet (p = 0.034). There were no significant changes observed over the six months in BMI and clinical outcomes among nutrition counseling patients. When comparing nutrition counseling patients to those who were referred but did not attend, we found at six months a higher percentage of nutrition counseling patients reportedly followed a high-fiber diet (p = 0.03), consumed two or more servings of fish per week (p = 0.01), followed a low-cholesterol diet (p = 0.03), and achieved a greater weight loss (p = 0.04) compared to the group that did not attend.

CONCLUSION

At six months we found that nutrition counseling using patient-centered methods appears to be an effective method for promoting changes in nutrient intake, diet habits, and, possibly, anthropometric measures in SLE patients. However, the counseling did not show a significant improvement in lipid levels, possibly due to short follow-up and/or SLE related factors.

Ablation of incisional atrial tachycardias using a three-dimensional nonfluoroscopic mapping system

Incisional atrial reentrant tachycardias are macroreentrant arrhythmias in which surgical scars or prosthetic material constitute one of the constraining barriers of the circuit. Accurate reconstruction based on fluoroscopy-guided endocardial mapping of the reentrant circuit is often incomplete and time consuming explaining, at least in part, the modest long-term results of this technique. Mapping and ablation of these arrhythmias using a three-dimensional nonfluoroscopic mapping system that allows electroanatomic reconstruction of the reentrant circuit could help in identifying the ablation targets and improve long-term outcome. The study included 20 patients (12 men, mean age 45+/-18 years) with corrected congenital heart disease (4 patients), coronary artery bypass surgery (7 patients), mitral or aortic valve replacement or reconstruction (6 patients), valve replacement and coronary revascularization (2 patients), and mitral valve replacement with maze procedure for atrial fibrillation (1 patient). Endocardial mapping with this novel system was complemented by standard electrophysiological techniques used to identify a critical isthmus of conduction. Two or more nonconductive areas of atrial tissue or surgical prosthetic material delimiting a critical isthmus of conduction were identified in every patient. Radiofrequency linear applications spanning two to more boundaries successfully eliminated the tachycardia in every patient. At a follow-up of 11.5+/-5.1 months (range 17-5 months), two (10%) patients developed a new clinical arrhythmia. The remaining 18 had no recurrences off medical therapy. Mean fluoroscopy time was 45.7+/-15.2 minutes for patients with a single scar and 89+/-41.2 minutes in patients with two or more scars. In conclusions, this new nonfluoroscopic mapping system offers the opportunity to achieve a high rate of cure of complex macroreentrant atrial tachycardias by facilitating reconstruction of the macroreentrant circuit and its boundaries.

Epicardial mapping and radiofrequency catheter ablation of ischemic ventricular tachycardia using a three-dimensional nonfluoroscopic mapping system

Endocardial radiofrequency catheter ablation of ischemic left ventricular tachycardia has been of variable success due to multiple factors. Two such factors include the location of the reentrant circuit in the deep myocardium or on the epicardial surface and the inherent limitations of fluoroscopy as a guide for target localization. We report a patient in whom successful epicardial mapping and radiofrequency catheter ablation of an ischemic left ventricular tachycardia was performed using pericardial access and the CARTO electroanatomic mapping system.

Tridimensional mapping: guided modification of the sinus node

Radiofrequency (RF) catheter modification of the sinus node appears to be a promising therapeutic modality for the treatment of inappropriate sinus tachycardia. Modification, as opposed to total obliteration, of the atrial pacemaker requires precise localization of the sinus node. This has been successfully achieved with a multicatheter approach guided by intracardiac echocardiography. This article describes the first clinical use of a tridimensional nonfluoroscopic mapping system to guide successful RF modification of the sinus node in two cases of inappropriate sinus tachycardia. This system simplifies the current approach and greatly reduces the fluoroscopy time.

Ablation of right and left ectopic atrial tachycardias using a three-dimensional nonfluoroscopic mapping system

We report our experience with mapping and ablation of right and left atrial tachycardia using a 3-dimensional nonfluoroscopic mapping system. Twenty-nine ectopic atrial tachycardias were successfully ablated. This novel mapping system has the potential to increase a successful cure of this arrhythmia by catheter ablation.

Erythropoietin use in pregnancy: two cases and a review of the literature

End-stage renal disease complicates only a small percentage of pregnancies, but, of these, virtually all become anemic due to a deficiency in erythropoietin. Erythropoietin has been shown to correct anemia due to renal disease in nonpregnant patients. We report two cases of erythropoietin use during pregnancy complicated by severe anemia due to renal failure. No maternal or fetal side effects were noted. Our two cases exemplify that erythropoietin is an effective means of treating anemia due to renal disease in the gravid patient.

Effect of left hepatic vein ligation on hepatic circulation, function, and microanatomy in dogs

Eighteen healthy dogs were allotted to 3 groups (n = 6 dogs each). All dogs were evaluated at the beginning of the study by complete physical examination; total and differential WBC counts; serum biochemical analysis (alanine transaminase and alkaline phosphatase activities and bilirubin and albumin concentrations); sulfobromophthalein excretion, ammonia tolerance, and glucagon response testing; portal and intraparenchymal pressure determinations; operative mesenteric portography; and histologic assessment of hepatic biopsy specimens. The left hepatic vein was ligated completely in dogs of groups 1 and 2. Group-3 (control) dogs had a ligature placed loosely around the left hepatic vein. Dogs of groups 1 and 3 were reevaluated 24 hours after surgery by use of the aforementioned hematologic and biochemical tests. Group-1 dogs were reevaluated by use of portal and intraparenchymal pressure determinations, jejunal vein portography, and complete necropsy at 48 hours after surgery. At 4 weeks after surgery, dogs of groups 2 and 3 were reevaluated by use of all aforementioned tests. Results indicated transient hepatic congestion, which resolved by the fourth postoperative week. Longstanding effect on hepatic structure, circulation, or function was not found. We concluded that left hepatic vein ligation in clinically normal dogs does not cause severe or permanent liver damage.